Provider Demographics
NPI:1184689523
Name:BAGAUTDINOV, NAIL (MD)
Entity type:Individual
Prefix:
First Name:NAIL
Middle Name:
Last Name:BAGAUTDINOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NAIL
Other - Middle Name:
Other - Last Name:BAGAOUTDINOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:701 W 189TH ST
Mailing Address - Street 2:APT 1 C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-4039
Mailing Address - Country:US
Mailing Address - Phone:646-510-4868
Mailing Address - Fax:
Practice Address - Street 1:701 W 189TH ST
Practice Address - Street 2:APT 1 C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-4039
Practice Address - Country:US
Practice Address - Phone:646-510-4868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39027207PE0004X
NY268055207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I30979Medicare UPIN